Introduction. Municipal eldercare is increasingly multifaceted. First line managers in nursing homes and home help services are responsible for personnel, budget and processes. The resources and work conditions of these managers have changed over time. The first line manager is often responsible not only for economic but also for quality development of their unit. Research focusing on first line management within municipal eldercare is lacking in specific contexts, for example, research on leadership in nursing homes and home help services.

Aims. The aim of this thesis is to study and analyze perceptions of leadership in eldercare. The main objective is to analyze differences in leaders’ and nursing assistants’ perceptions of leadership in nursing homes and home help services, and to study leadership factors and their associations with psychosocial work environment among nursing assistants who are engaged in eldercare.

Design and methods. This thesis is based on two studies, and uses cross-sectional data from two different surveys: the Developmental Leadership Questionnaire, DLQ (Larsson, 2006a) and a Questionnaire for Psychological and Social factors at Work, QPS, (Dallner, et al.,2000). Assessments from 21 leaders and 95 nursing assistants in nursing homes and home help services were analyzed in study I. Assessments from 1132 nursing assistants in nursing homes and in home help services (n=844 nursing homes and n=288, home help service units) were analyzed in article II. The data were analyzed with descriptive and analytic statistics.

Results. Nursing assistants in nursing homes assessed their leaders to be more controlling and observant than nursing assistants in home help services. According the leaders self assessment, leaders in home help services were less successful at being supportive, being a good example, and promoting creativity than leaders in nursing homes. Psychosocial work environment was related to leadership factors, but stronger associations occurred more frequently in nursing homes than in home help services. The leadership factors empowering leadership, support from superiors, focus on human resources and control over decisions were associated with better results on all the variables that were related to the psychosocial work environment in both nursing homes and in home help services.

Conclusions and implications for practice. Organisational differences in conducting leadership in old age care must be considered. Some leadership characteristics are better conditions for creating and maintaining a positive psychosocial work environment for nursing assistants in nursing homes and home help services. Due to the differences in organisational settings, it is important to consider the differences in conditions for conducting leadership. To influence nursing assistants’ performance and to increase quality in eldercare in the long term, appropriate leadership is necessary. Therefore, it is important for the leaders to provide support in work, help to develop skills, encourage employees to participate in important decisions, and show interest in nursing assistants’ well-being. Also, the leaders might benefit if they reduce the specialisation of work, which counteracts the possibility to have variation in work in nursing homes and home help services. In particular, nursing homes should benefit if they reduce the amount of role conflicts, and if nursing assistants receive reasonable quantitative work demands. The municipality eldercare should take into account the organisational differences in conducting leadership in nursing homes in relation to home help services. Recruiting leaders with characteristics that are desirable in the specific context will create better conditions for a good psychosocial work environment in nursing homes and home help services.

Background

Municipal elder care has become increasingly multifaceted, and the quest for quality is a continuing discussion in Swedish elder care. In recent decades, municipalities have prioritized older adults with severe needs. There is also a trend of more elderly individuals receiving care in their own homes. The number of persons 80 years and older will increase by approximately 75 percent between 2015 and 2035. During the same period, the numbers of nursing assistants are likely to decrease. Furthermore, health and social care services have the highest rates of sick leave in Sweden, and the psychosocial work environment plays an important role in reducing sick leave. Perceived support from an organization, leaders and colleagues has been shown to have a positive effect on nursing assistants’ perceptions of the psychosocial work environment in elder care settings. Leadership characteristics or attributes and behaviours have been associated with a healthy work environment. Thus, knowledge regarding the associations between leadership, the psychosocial work environment, and recipient satisfaction in elder care is insufficient.

Aims

The overall aim of this thesis was to explore and describe the associations between leadership, the psychosocial work environment, and recipient satisfaction in municipal elder care, the changes over time in psychosocial work environment, and the difference between nursing homes and home care.

Design and methods

This thesis is based on four cross-sectional studies (I-IV) and one study based on repeated cross-sectional analyses (V). Data from three different surveys were used: the Developmental Leadership Questionnaire (DLQ), the Questionnaire for Psychological and Social Factors at Work (QPS), and a recipient satisfaction survey (based on a National Board of Health and Welfare recipient satisfaction survey). Study I analyses first-line managers’ assessments of their leadership and nursing assistants’ assessments of their first-line managers. Study II analyses the associations between leadership and the psychosocial work environment, study III the associations between psychosocial work environment and recipient satisfaction, and study IV encompasses all three levels, leadership and the psychosocial work environment, and recipient satisfaction. Study V describes changes in the psychosocial work environment between 2007 and 2015.

Results

There are structural differences between nursing homes and home care in the assessments of leadership, the psychosocial work environment, and satisfaction among older people. Linear trends for the period 2007-2015 demonstrate a decline in control at work in both nursing homes and home care and positive trends for stimulus from the work itself. The results also show that nursing assistants in nursing homes rate their psychosocial work environment higher than nursing assistants in home care. Older adults receiving home care report higher satisfaction than those receiving care in nursing homes. In contrast, nursing assistants in home care rate their first-line managers’ leadership and their perceived psychosocial work environment lower than those working in nursing homes. Process-related factors, for example, the association between leadership and the psychosocial work environment, showed that interpersonal factors, such as support from superiors, empowering leadership, human resource primacy, and direct leadership, may impact nursing assistants’ psychosocial work environment in both nursing homes and home care. A better psychosocial work environment among nursing assistants was associated with higher satisfaction among recipients of elder care, except for the recipient satisfaction item staff knowledge, which had negative associations with the psychosocial work environment.

Conclusions and implications for practice

To influence nursing assistants’ performance, to increase recipient satisfaction and to increase quality in eldercare in the long term, appropriate leadership and a healthy psychosocial work environment are necessary. To make the most out of the available resources and to meet future challenges (among others) in elder care require organizational attention so that leadership and psychosocial work environments continue to develop in both nursing homes and home care. Therefore, structural differences in elder care must be considered to create a better psychosocial work environment for nursing assistants and, in turn, to create higher care satisfaction for those who are receiving elder care in two different social contexts.